HomeMy WebLinkAboutSeptic Pumping Slip - 158 FOREST STREET 9/26/2017Commonwealth of Massachusetts
City/Town of
System Pumping.Record
Form 4
SEE 2 6 2 017
TOWN OF NORTH ANDOVER
• HEALTH DEPARTMENT
/a6.4
DEP has provided this form' for use.by local Boards Of Health. Other forms may be used, but the
informationmust be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The ,System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1, System Location: Left t front of hous , Left / Right rear of house, Left / right side of house, Left /
buildirig, Left / Right rear of building, Under deck
54
Right side of building,
Addr
City/T
2. System Owner
State
Name
Address (if different from location)
City/Town
State.
Zip d
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type -of system 0 Cesspool(s) 0--Sgrafic Tank
Other (describe):
Date
2. Quantity Pumped:
Gallons
Tight Tank
4. Effluent Tee Filter present? 0 Yes 0-440-- If yes, was it cleaned? 0 Yes 0 No
' 5. Condition of System:
6. System Pumped By:
Neil. Bates -on •
' Name
Bateson Enterprises Inc
Company
7. Location where contents -were disposed:
Lowell Waste Water
Sign
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1